Provider Demographics
NPI:1255688628
Name:DICKSON, MELANIE ELAINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:ELAINE
Last Name:DICKSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 SE 132ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3318
Mailing Address - Country:US
Mailing Address - Phone:503-760-7073
Mailing Address - Fax:
Practice Address - Street 1:12441 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1053
Practice Address - Country:US
Practice Address - Phone:503-255-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-05
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11322235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist